renal stones Dörthe and Jo Case Study Bob 70 years old 1 month history intermittent back pain HPC S lumbosacral Q Dull achy sensation Sometimes sharp I ID: 458709
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Slide1
PVD, AAA and renal stones
Dörthe and JoSlide2
Case Study
Bob, 70
years
old1 month history intermittent back painSlide3
HPC
S
lumbosacral
QDull
achy
sensation
Sometimes
sharp
I
5-7 /10
T
Intermittent
Varies
in
duration
A
Low
back
movement
,
standing
,
sitting
,
driving
Partially
relieved
by
tramadol
R
Radiates
to
posterior
leg
S
No
morning
stiffness
No
bowel
/
bladder
problem
No
lower
limb
weakness
or
tingling
sensation
No
weight
loss
or
fever
No
interruption
to
walking
No
recent trauma/heavy
liftingSlide4
PMH/ Risk factors
Risk
factor
Importance / RelevanceHypertension
Hypercholesterolaemia
Smoking
Diabetes
Atherosclerosis
Age
5% of
population over 60
15% of population over 80
FHx
Genetic
in 10-20%
of
First
degree
relatives
Marfan’s
Ehler’s
Danlos
Gender
Male
to
female
ratio 6:1Slide5
Presenting complaint of AAASlide6
On Examination
Feel
above the umbilicus for aortic aneurysmIf leaking or
rupture
Slide7
Definition
Abnormal
dilatation of
abdominal aorta over 2x the normal size (2cm) or enlargement over 3cmMost commonly
affects
infrarenal
aorta 95%
with
iliac
involvement
in 30%
6000
deaths per year in england and walesSlide8
True or false aneurysm?
True
aneurysm
Dilatation of all three layers of vesselFalse aneurysm
Dilatation of
artery
not
involving
all
three
layersSlide9
Aetiology
Atherosclerotic
in 95%
5% inflammatoryOthersTraumaticInfective (mycotic aneurysm)
CTD –
Ehler’s
Danlos,MarfansSlide10
Pathophysiology
Decrease
of
amount of medial and adventitial elastinOther possible places
Aorta
Iliac
Popliteal
Femoral arteriesSlide11
Investigations
Acute
– CT scan,
Bloods, ECGUS for screening purposes ( over 65 )AAA on AXR – eggshell appearance due to calcification
aneurysm
wallSlide12
Management
Conservative
If
asymptomaticUnder 5.5cmRegular follow ups with USManagement of cardiovascular
risk
factors
Surgical
Prosthetic
graft
placement
–
rewrapping
of
native aneurysm around
to
reduce
incidence
of
enterograft
fistula
formation
Endovascular
EVAR –
placement
stent
through
distant
percutaneous
accessSlide13
Criteria for surgery
AAA over 5.5 cm
Rupture
Rapid growthEmbolisation of plaque
S
ymptomaticSlide14
Complications
General
Risk
of rupture Under 5cm – 4%5-7cm diameter – 7%More than 7cm – 20%Rupture
Distal
embolus
Sudden
complete
thrombosis
Fistulae
formation
Infection
Of surgery
Elective
mortality
– under 4%
Emergency
surgery
mortality
50%
Haemorrhage
Graft
infection
Thrombosis/embolism
Colonic
ischaemia
Renal
failureSlide15
Peripheral vascular diseaseSlide16
Definition
Also
called peripheral arterial diseaseOcclusive atherosclerotic disease in lower
extremities
Occlusion
distal
to
aortic
arch
Up to 12% of 55-70year
old
affectedRare causes – vasculitis,
Buerger’s
diseaseSlide17
Atherosclerosis
Atheromas
containing cholesterol and lipid form within intima and inner media, often
accompanied
by
ulceration
and
smooth
muscle
hyperplasia
Risk
factors –
hypertension, smoking, diabetes, FHx, hypercholesterolaemia, high LDL,
obesitySlide18Slide19
PresentationSlide20
On examination
Legs
Weak
/ absent pulsesReduced CRTCold, pale legsHair loss
Atrophic
skin
changes
Painful
,
punched
out
ulcers
–
pressure
areasvenous ulceration – medial
malleolus
Also
examine
CVSSlide21
Investigations
Handheld
DopplerABPI Normal= 1, claudication <0.6, rest pain <0.4Bloods –anaemia, ESR,
thrombophilia
screen,
lipids
ECG - ?CAD
Arterial
Duplex
CT
angiogram
AngiogramSlide22
Cx of PVD
Amputation
Gangrene
Dry – dry necrosis of tissue without signs of infection
Wet
–
moist
necrotic
tissue
with
signs
of infectionUlcersRisk of limb
loss
with
claudication
5% per
year
Risk
of
limb
loss
with
rest
pain
over 50% per
yearSlide23
Management – Conservative and MedicalSlide24
Surgical Management
Indications
Disabling
claudicationCritical ischaemiaWeak/absent femoral pulsesAngioplasty +- stenting
Surgical
bypass
graftSlide25
Prognosis
High
risk for all-risk mortality, especially cardiovascular15% progress to critical
ischaemia
50%
improve
25%
stabilise
20%
worsen
20%
need
intervention
8%
need amputation